Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety

Middle age male

 

Decision Point One


Begin Buspirone 10 mg orally BID

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


Increase buspirone to 10 mg orally TID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports no change in his anxiety
  • HAM-A score has decreased from 23 to 22
Decision Point Three
Select what the PMHNP should do next:


Continue current dose and reassess in 4 more weeks
Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, the PMHNP can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.

Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. The PMHNP should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
Augment with Ativan (lorazepam) 0.5 mg orally TID
Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, the PMHNP can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.

Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. The PMHNP should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
Discontinue buspirone and begin Zoloft 50 mg orally daily
Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, the PMHNP can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.

Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. The PMHNP should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
Increase buspirone to 20 mg orally TID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports nausea, dizziness, nervousness, headaches, and dry mouth
  • HAM-A score reveals no change and he reports that he still feels anxious
Decision Point Three
Select what the PMHNP should do next:


Decrease BuSpar to 15 mg orally TID
Guidance to Student
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.

It would not be appropriate to explain to the client that these are “normal side effects” and continue the same dose with a plan to reassess in 4 weeks. Recall that the onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work at all.

The buspirone at this point meets the criteria for treatment failure (as it failed to result in at least a 25% decrease in symptoms), thus it would be appropriate to discontinue and begin a first line agent such as an SSIR (like Zoloft 50 mg orally daily) at this point.
Explain to the client that these are normal side effects of buspirone and maintain current dose for another 4 weeks
Guidance to Student
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.

It would not be appropriate to explain to the client that these are “normal side effects” and continue the same dose with a plan to reassess in 4 weeks. Recall that the onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work at all.

The buspirone at this point meets the criteria for treatment failure (as it failed to result in at least a 25% decrease in symptoms), thus it would be appropriate to discontinue and begin a first line agent such as an SSIR (like Zoloft 50 mg orally daily) at this point.
Discontinue buspirone and begin Zoloft 50 mg orally daily
Guidance to Student
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.

It would not be appropriate to explain to the client that these are “normal side effects” and continue the same dose with a plan to reassess in 4 weeks. Recall that the onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work at all.

The buspirone at this point meets the criteria for treatment failure (as it failed to result in at least a 25% decrease in symptoms), thus it would be appropriate to discontinue and begin a first line agent such as an SSIR (like Zoloft 50 mg orally daily) at this point.
Discontinue buspirone and begin Lexapro 10 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports that he feels “great”
  • Client states that his anxiety is getting “better”
  • HAM-A score has decreased from 23 to 13
  • Client does report that he sometimes feels sleepy for a few hours after taking the medication, but “perks up” by early to midafternoon
Decision Point Three
Select what the PMHNP should do next:


Increase Lexapro to 15 mg orally daily in AM
Guidance to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.
Continue same dose of Lexapro but change administration time to bedtime
Guidance to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.
Re-start BuSpar at 10 mg orally TID
Guidance to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.